Implementing EBP and QI are recognized as crucial competencies that should be held by all healthcare professionals. Clinical research, EBP, and QI are separate but interrelated areas of investigation [9, 10]. QI is described as systematic, information-driven change-focused activities designed to improve healthcare [3]. Although EBP was considered the gold standard and a problem-solving approach to deliver safe and high-quality patient care [5], QI was found to be a vital contextual organizational factor for the adoption of EBP and can be used to validate the introduction of EBPs [3] while clinical research offers empirical evidence for EBP [10]. To significantly influence the improvement of quality in healthcare, there is a need to apply evidence-based practice (EBP). Without EBP, healthcare providers are at risk for variances in care that could seriously affect patient outcomes [11]. The inconsistent incorporation of research evidence into clinical practice persists, amid guidance and market pressure, and the gap between research evidence and EBP is frequently reported [12]. Also, few empirical studies have investigated EBP in relation to QI [4].

Egyptian Hospital Accreditation Program complements that quality is improved when the hospital ensures that care follows “best practices” that are based on professional and evidence-based literature, not on individual opinion or routine. Consequently, the demand for quality improvement in hospitals is growing [13]. Nurses play a critical role in improving healthcare quality and their work has a significant effect on the patients’ care and health since they are actively involved in almost all aspects of hospital quality. Based on this assumption, nurses are at the heart of the system and considered the best people to work towards improving the processes by which quality care is delivered in the healthcare setting [14].

The World Health Organization, in particular, has suggested that nursing in Egypt is one of the skilled professions that has faced many challenges in past years. The key nursing problems are focused on education, performance, and little institutional recognition or support in the workplace. Healthcare organizations are now challenged to improve nurses’ skills and knowledge of emerging professional health expertise through ongoing training and development [15]. Nurses have traditionally relied on the professional opinions of experienced nurses in clinical decision-making [16]. But these conventional methods are not only outdated but also unsafe. Also, experienced-based knowledge can also be linked to biased thinking, which leads to errors. Nowadays, as they are interested in clinical decision-making, nurses are forced to integrate scientific findings and make appropriate and justifiable decisions in their practice [1, 2].

Implementation of evidence-based practice (EBP) in health care organizations is recognized as a clinical practice challenge. It requires a comprehensive collection of skills to formulate questions that occur during the work and the ability to perform analysis on it, objectively analyze information, and implement outcomes in the patient care process [11, 17]. Despite the availability of innovative research-based knowledge and published papers with the potential to increase the quality of nursing care and progress on EBP, nursing practice is still not evidence-based [4, 16].

Other studies showed that nurses rarely integrate research findings into their practice and may not be well trained for EBP. They lack adequate knowledge of evidence-based concepts and use them to a limited level [18-20]. Many nurses reported that they do not know how to find the appropriate research reports and have difficulty in identifying clinical practice implications of the research findings [18]. Thus, they tend to use knowledge from experience and social interactions and only a small percentage of nurses consistently use EBP [18-20]. Moreover, despite the benefits of EBP, there are numerous barriers hampering the adoption and use of EBP and research continues to find inconsistencies in its implementation in the clinical work environment [1, 16]. Hence, it seems imperative to overcome the obstacles and promote facilitators in order to adopt the best evidence and improve care delivery and patient outcomes ‎ [9]‎.

Notably, the majority of studies examine nurses' and other healthcare professionals' views on EBP and barriers encountered, yet when it comes to its relation to quality improvement among Egyptian nurses, the evidence is somewhat limited. In the Egyptian context, the culture in healthcare agencies and schools of nursing did not encourage the utilization of EBP and EBP literacy. Considering the novelty of EBP’s ideas in nursing education, most Egyptian nursing research focused on the understanding of nursing educators’ evidence-based practice [21-24] with delimited research targeting nurses in clinical settings [23]. It is believed that the health care system does not have empowered nurses to engage in research and EBP [23, 24]. This could impede the translation of the research activities into a unified EBP framework. Even with the growing focus on EBP, little is known about current EBP’s knowledge, skills, and attitude and its relationship to QI among nurses in Egyptian hospitals, and the barriers that could be faced in EBP applications. To the best of the researchers’ knowledge, there is a paucity of research in the clinical sector, and there is no previous study targeting EBP and its relationship to QI in different health sectors.

Hence, it is important and timely to explore the factors that can help nurses and policymakers gain more insight into the obstacles to adopt and implement EBP in nursing and how this can apply to QI. Therefore, the present research was targeted to contribute to this research gap. ‎

The main objectives of this research were to: assess nurses’ perception of knowledge, skills, and attitude in EBP and QI, and investigate the relationship between EBP and QI.

Further objectives were to identify the barriers and facilitators nurses perceived for EBP and to identify the individual and work-related characteristics that might be associated with the perception of EBP and QI.

A cross-sectional descriptive research design was conducted in inpatient care units at three Egyptian hospitals associated with various health sectors in Alexandria City: namely Hospital 1, which is a non-profit teaching hospital associated with Alexandria University with a capacity of 300 beds; Hospital 2 is a government hospital affiliated with the Ministry of Health, with a total of 130 beds; Hospital 3 is a for-profit private health sector-related, with a capacity of 100 beds. These hospitals play a major role in providing extensive and multi-specialty healthcare services in many regions/ governorates in Egypt, including medical, surgical, emergency, and multi-specialty care.

‎A convenience sample of staff nurses, working at the aforementioned hospitals, was invited to take part in the study (N=300). Convenience sampling (also known as availability sampling) is a particular form of non-probability sampling technique that relies on data collection from a population willing to participate in the study. Inclusion criteria included all nurses who have at least six months of experience in their hospitals and willingness to participate, while nurses less than six months of experience and interns were excluded. The sample size was calculated using the “Epi info program version 7” based on a 5% variance, 95% confidence level, and 0.80 power, and the minimum sample size was 100 nurses from each hospital.

The study tools were translated into Arabic to suit the culture of the participants and tested for content validity along with the fluidity of the translation in the field of study by a jury of academic members. A minor modification was made in rewording few statements according to the received feedback. The study instruments were tested for internal reliability using Cronbach's alpha correlation coefficient. The findings proved both EBPQ and QIQ as reliable tools, with correlation coefficient α of 0.94 and 0.91, respectively. Moreover, a pilot study was achieved with 30 nurses (10%) on 10 nurses from each hospital who were excluded from the study subjects.

To collect the required data, official approval was obtained from the administrators in the specified hospitals. Upon receiving their approval, the questionnaires were hand-delivered in a paper format by the first author with specific guidance to nurses. According to their work shifts and break time described by each unit nurse manager, the author approached nurses. A final of 300 completed questionnaires were collected over three months (May-July 2018).

Approval was received from the Faculty of Nursing, University of Alexandria. The researchers clarified to all participants the purpose of the study. Data privacy and confidentiality were maintained and ensured by obtaining informed consent. Participants were granted anonymity and the right to withdraw from the study at any time.

Data were analyzed using IBM SPSS version 22. The internal consistencies of the EBPQ and QI scales were determined with Cronbach’s alpha coefficients. The normality of the data was obtained through descriptive statistics of means, standard deviations, and frequencies. Data on the general features of nurses, EBP, and QI levels are summarized using frequencies, percentages, mean, and standard deviations (SDs). For each EBP and QI subscale, the mean scores were added. Content analysis was used for the two open-ended questions regarding perceived barriers and facilitators to the implementation of EBP. In order to identify the single largest barriers and facilitators, the frequencies and percentages of respondents who reported each barrier and facilitator were calculated, and items were ranked in order accordingly.

Analyses of variance (ANOVA) was used to analyze variations in EBPQ and QI scores among hospitals and in relation to participants’ individual and work-related characteristics and Pearson’s correlation test was used to assess the relationship between the EBP and QI. The Regression Analysis (R²) has been used to test the independent variable (QI) predictive power on the dependent variable (EBP). R² change was tested with the F-test. A significant F value for R² meant that the QI added a significant prediction of EBP. Based on the univariate analysis, stepwise multiple regression analyses were performed to determine factors associated with EBP and QI levels, respectively. Nurses’ age, years of nursing experience, and educational level were significantly correlated with the scores for both EBPQ and QI scales; hence, we utilized the overall scale scores in the analysis. The statistical significance point has been set at p ≤0.05.

The general characteristics of the respondents are shown in Table 1. The majority (75.7%) of the nurses surveyed were female, and 42.3% were between the age of 30 and under 40 years old. Nurses were distributed between 23.0% and 26.7% across different units of work. Approximately one-quarter of nurses (26.7%) worked in ICUs and the same proportion worked in miscellaneous (multi-specialty) units. The highest percentage of nurses (43.3%) held a bachelor’s nursing degree, while 39.0% had a high school diploma. In addition, 38.3% of nurses had less than five years of experience, while 10.7% had more than 20 years of nursing experience. Approximately two-thirds (65.3%) of nurses were verified to have previous EBP information, 81.63% of them referred to the previous study as the main source of this information.

With regard to the perception of research variables, Table 2 indicates that the mean score and standard deviation of the perception of overall EBP by nurses are moderate (3.57±0.70) with the highest mean for attitudes towards EBP (4.80±1.18), followed by the use of EBP (3.57±1.20) and EBP knowledge (3.22±0.68). Additionally, Table 2 reveals no significant difference among nurses’ groups at the three studied hospitals regarding their perception of overall EBP (F =0.832, p= 0.436). Only a significant difference was found among nurses’ groups regarding their attitudes toward EBP (F=3.469, p= 0.032). Nurses at hospital 3 (profit hospital) reported higher attitudes towards EBP than nurses in hospitals 1 and 2 (university and governmental hospitals). On the other hand, significant differences were found among nurses’ groups regarding their perception of overall QI (F =4.638, p= 0.010) and related subscales (p<0.05). Nurses at hospital 3 reported higher QI knowledge (F =3.200, p=0.042), attitudes towards QI (F =5.206, p=0.006), and QI skills (F =0.5.464, p= 0.005) than nurses in hospitals 1 and 2.

In response to the two open-ended questions asking about perceived barriers and facilitators to the implementation of EBP, the number of nurses responded to these questions was 201(67.0%). Some nurses identified more than one barrier or facilitator. The most widely identified obstacles to EBP were: lack of time for reading and searching (100.0%), lack of adequate staff knowledge and skills of EBP (93.75%), inadequate training of nurses on EBP, especially diploma degrees (64.38%), and inadequate resources and facilities (56.25%). On the contrary, the most important facilitators that could help nurses use EBP were periodic training programs on EBP and updated nursing research (100.0%), supportive hospital management (79.60%), and the presence of facilities and role models for applying knowledge and skills of EBP (44.78%). See Supplementary Table 1.

Table 3 indicates a strong positive, moderate correlation between the EBP and QI, as perceived by nurses (r= 0.485, p<0.001). The coefficient of regression between QI and its related dimensions, as independent variables, and EBP, as a dependent variable, was R²=0.273. This means that approximately 27.3% of the explained variance of EBP is accounted for QI and associated subscales, particularly, QI knowledge and skills that contribute important prediction of EBP where the regression model is significant (F= 36.973, p<0.001). For further correlation values, see Supplementary Table 2.

Table 4 showed the stepwise regression analysis, which revealed that the overall EBP score was significantly associated with nurses’ age, years of experience, and educational level. Younger nurses had the lowest perceived EBP score (β=-4.457,p<0.001), whereas nurses with more years of experience and a bachelor’s education degree had higher EBP scores (β=3.564, p<0.001; β=2.065, p=0.005), respectively. As for QI, the result showed that age and educational level were statistically important factors correlated with the QI ratings. Specifically, younger nurses (β=-2,994, p= 0.046) had a lower perceived QI rating, while bachelor’s nurses had a higher QI rating (β=3,697, p<0.001).

Although the study findings contributed to the current knowledge about EBP and QI among Egyptian nurses, the results of this study should be viewed cautiously, considering it has some limitations. Future research might address these limitations. First, this study was based on self-reported data from one culture, which may represent an inherent bias. It is recommended to explore the relationships between EBP and QI using different methodologies, such as knowledge assessment tests and observation-based performance testing, while including more nurses in more varied healthcare settings and cultures for generalization. Second, the study focused on individual characteristics associated with the perception of EBP and QI and did not include organizational factors, such as nursing leadership and organizational culture. Therefore, future studies are recommended to include these variables.